Basic Information
| Provider Information | |||||||||
| NPI: | 1548294176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SODERSTROM | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5131 W BRISTOL RD | ||||||||
| Address2: | STE A | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107332090 | ||||||||
| FaxNumber: | 6304951770 | ||||||||
| Practice Location | |||||||||
| Address1: | G-5131 WEST BRISTOL RD | ||||||||
| Address2: | STE A | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107332090 | ||||||||
| FaxNumber: | 8107330387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 4301032434 | MI | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 0257159 | 01 | MI | BLUE CARE NETWORK MICHIGA | OTHER | 0771592 | 01 | MI | HEALTHPLUS OF MICHIGAN | OTHER | 1421419 | 05 | MI | MEDICAID |